0:00

This is the case of a 65-year-old with a PSA rising to 5.

0:05

We have our axial T2, our ADC maps, which are

0:09

windowed at a window level of 1400x1400, our

0:13

high B-value image, and a post-contrast image.

0:18

I believe this is a delayed,

0:19

it's not an arterial phase image.

0:22

So, what's nice about this case is,

0:25

it's a very good example.

0:27

Of how when you render your ADC map correctly,

0:31

focal tours in the peripheral zone can look just

0:34

like little black holes on a background of white.

0:36

So there are four errors in the

0:37

peripheral zone in this case.

0:39

One here, one here, one here, and here.

0:45

We have well-defined black holes on the ADC

0:48

map on a background of normal, high signal.

0:52

Each one of these has diffusion characteristics of

0:55

a PI-RADS 4 lesion in that they're dark on the ADC

0:58

map, and I like to use a cutoff of ADC of 1000, and

1:02

they're bright on the interpolated high B-value images.

1:05

So, dark, bright.

1:08

Dark, bright, dark, bright, and I'm gonna

1:15

go lower, this guy here, dark, bright.

1:19

They all also have correlates on the T2 images,

1:22

so here's a nice little well-defined low T2 signal

1:25

nodule you can almost pluck out of the gland.

1:28

And then here's another one, and then

1:30

here's another one, here's another one.

1:33

On prior cases, we talked about the ejaculatory ducts

1:36

being located in the midline, having a triangular shape.

1:39

But the ejaculatory ducts are located in the base

1:42

and mid-gland, and they disappear by the apex.

1:45

This is the apical part of the gland.

1:47

This is too far inferior to be an ejaculatory duct.

1:50

Those ducts would be located somewhere up here.

1:53

Now, given that these are already PI-RADS 4 lesions, it

1:56

doesn't matter what they do on the post-contrast images.

1:59

So we don't need to worry about that,

2:00

we don't have an arterial phase.

2:02

Each one of these areas was targeted and resulted

2:05

in a Gleason 3 plus 4 or higher histology.

2:09

Uh, so the PI-RADS nomenclature worked nicely in this case.

2:13

In the transition zone, which is mildly

2:15

enlarged, you have the normal heterogeneous

2:18

appearance of prostatic hypertrophy.

2:20

Here we have some thickened anterior stroma.

2:23

It's, uh, crescentric, it parallels the margin,

2:27

it's on both sides, uh, it does not enhance.

2:30

I find the lack of enhancement is the

2:33

best tip for identifying anterior stroma.